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Assessment for weight-related comorbidities in children and adolescents with obesity[1-5]

Assessment for weight-related comorbidities in children and adolescents with obesity[1-5]
Condition Clinical presentation/examination Tests Notes
Dyslipidemia Asymptomatic or family history of CVD Screening test:
  • Fasting lipid profile

Timing:

  • Screen at age ≥10 years for all children with overweight or obesity[3]
  • Evaluate earlier for selected children with multiple risk factors
  • Additional risk factors include family history of CVD, other obesity comorbidities (hypertension, diabetes), or tobacco use
  • Refer to UpToDate content on dyslipidemia in children for interpretation and follow-up
Hypertension Asymptomatic; detected on routine monitoring Screening test:
  • BP measurement

Timing:

  • Measure at all health care visits (and at least annually)
  • Use appropriately sized cuffs and age-appropriate norms
  • Multiple measurements are required to diagnose or exclude hypertension
Follow-up tests:
  • 24-hour ABPM
  • CBC, metabolic panel, renin assay, urinalysis, kidney ultrasound
  • ABPM is used to evaluate for "masked" hypertension; rule out "white coat" hypertension
  • ABPM is suggested if the diagnosis is unclear from random office BP measurements
  • Blood tests are suggested if hypertension is confirmed to exclude other causes of hypertension
Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly termed nonalcoholic fatty liver disease) Generally asymptomatic; may have RUQ tenderness or hepatomegaly Screening test:
  • Serum ALT

Timing:

  • Initiate screening with serum ALT for all children with obesity starting at ≥10 years
  • If ALT is normal, repeat at least every 2 to 3 years*
  • Diagnosis also depends on cardiometabolic risk factors (lipids and HbA1c or fasting glucose)
Follow-up tests:
  • Abdominal ultrasound to evaluate for anatomical abnormalities
  • Laboratory tests for cardiometabolic risk factors; evaluation for viral hepatitis, autoimmune hepatitis, and endocrine disorders
  • Exclude genetic disorders in selected patients
  • Liver biopsy
  • Perform these follow-up tests if ALT is >80 units/L, persistently elevated >2 times the ULN* for 6 months, or other signs/symptoms of advanced liver disease are present
  • The purpose of follow-up tests is to determine the cause of elevated transaminases
  • Liver biopsy may be helpful in some cases, such as when diagnosis is uncertain or there is concern for severe progression
  • A definitive diagnosis of MASH can only be made by liver biopsy, but this is not always necessary for clinical management (refer to UpToDate content on MASLD)
Gallbladder disease Recurrent RUQ abdominal pain, sometimes with fatty food intolerance, nausea, vomiting, or jaundice
  • Abdominal ultrasound
  • AST, ALT, GGTP, total bilirubin
  • Amylase, lipase
  • Complications may include acute pancreatitis or cholangitis
Type 2 diabetes mellitus or impaired glucose tolerance Often asymptomatic; may present with urinary frequency, nocturia, polydipsia, or polyuria Screening test:
  • Fasting glucose, HbA1c, or oral glucose tolerance test

Indications:

  • Perform in children ≥10 years old with overweight or obesity and 1 or more risk factors for type 2 diabetesΔ
  • Diabetes is diagnosed if fasting glucose ≥126 mg/dL or HbA1c ≥6.5% on 2 occasions
  • Prediabetes is diagnosed if fasting glucose 100 to 125 mg/dL or HbA1c 5.7 to 6.4% on 2 occasions
Sleep apnea Habitual snoring, mouth breathing, daytime sleepiness, or inattentive behaviors and/or adenotonsillar hypertrophy Screening:
  • Routinely evaluate signs and symptoms
  • Assess tonsil size

Diagnostic test:

  • Polysomnogram (sleep study)
  • Perform polysomnogram in patients who have obesity and symptoms suggesting obstructive sleep apnea◊
SCFE Unexplained limp or aching pain in hip, groin, thigh, or knee
  • Hip radiographs
  • Use frog-leg positioning for radiograph
  • Children with acute symptoms of SCFE should immediately stop all weightbearing activity (including walking) to prevent further displacement[3]
Varus (Blount disease) or valgus deformity Varum (bow legs) or varus (knock knees) deformity on examination, with or without knee pain
  • Knee radiographs
  
Polycystic ovary syndrome Menstrual irregularity, excessive acne, hirsutism Initial tests:
  • Total testosterone (or free testosterone)
  • Beta-hCG, TSH, prolactin, DHEAS, 17-hydroxyprogesterone (early morning)
  • Initial tests are to confirm whether hyperandrogenemia is present and exclude other causes of hyperandrogenemia and/or abnormal menses
  • If laboratory testing is abnormal, additional workup is indicated
Impaired kidney function Asymptomatic Screening:
  • BUN, creatinine
  • Urine for UACR

Indications:

  • Perform in adolescents with type 2 diabetes, hypertension, or severe obesity§
  • UACR >30 mg/g is abnormal
Precocious puberty Appearance of secondary sexual characteristics <8 years (females) or <9 years (males) Initial tests:
  • LH and FSH
  • Estradiol (females)
  • Testosterone or free testosterone (males, or females with virilization) 
  • Physical examination is often sufficient to evaluate
  • Laboratory testing depends on child's age and pubertal progression
  • Central nervous system imaging may be indicated in selected children with central precocious puberty
Pseudotumor cerebri Headaches (especially morning), nausea/vomiting, blurred or decreased vision Initial test:
  • Funduscopic examination and/or refer to pediatric neurologist or ophthalmologist
  • Increased intracranial pressure suggested by papilledema and confirmed by lumbar puncture
This table summarizes the evaluation for obesity-related comorbidities in children. For details on the evaluation, refer to UpToDate content on the health consequences of obesity in children and adolescents and relevant topic reviews.

ABPM: ambulatory blood pressure monitoring; ALT: alanine aminotransferase; AST: aspartate aminotransferase; BP: blood pressure; BUN: blood urea nitrogen; CBC: complete blood count; CVD: cardiovascular disease; DHEAS: dehydroepiandrosterone sulfate; FSH: follicle-stimulating hormone; GGTP: gamma-glutamyl transpeptidase; HbA1c: glycated hemoglobin; hCG: human chorionic gonadotropin; LH: luteinizing hormone; MASH: metabolic dysfunction-associated steatohepatitis; MASLD: metabolic dysfunction-associated steatotic liver disease; RUQ: right upper quadrant; SCFE: slipped capital femoral epiphysis; TSH: thyroid-stimulating hormone; UACR: urine albumin-to-creatinine ratio; ULN: upper limit of normal.

* For interpretation of serum ALT, use the ULN of 22 units/L for females and 26 units/L for males, as determined from healthy lean children in the National Health and Nutrition Examination Survey[4]. Note that these values are substantially lower than the ULNs reported in most pediatric hospital laboratories.

¶ Screening laboratory tests for suspected MASLD include a CBC with platelets, HbA1c, and lipid panel.

Δ Risk factors for type 2 diabetes include: family history of type 2 diabetes, high-risk race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander), signs of insulin resistance (eg, acanthosis nigricans), or conditions associated with diabetes (hypertension, dyslipidemia, polycystic ovary syndrome).

◊ Symptoms suggesting obstructive sleep apnea include persistent snoring (most nights, most sleeping positions), observed gasping or apneas, nocturnal enuresis, and morning headaches.

§ Screening for impaired kidney function is recommended for patients with type 2 diabetes[5]. If the initial test is abnormal, repeat with confirmation in 2 out of 3 samples over 6 months. UpToDate authors also suggest this screening for patients with other risk factors for developing chronic kidney disease, including hypertension or severe obesity.

References:
  1. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Pediatrics 2011; 128:S213.
  2. de Ferranti SD, Steinberger J, Ameduri R, et al. Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e603.
  3. Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics 2023; 151:e2022060640.
  4. Vos MB, Abrams SH, Barlow SE, et al. NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr 2017; 64:319.
  5. American Diabetes Association Professional Practice Committee. 14. Children and adolescents: Standards of care in diabetes—2024. Diabetes Care 2024; 47:S258.
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